Risk Factors for COVID-19 Associated Mucormycosis: The Ophthalmologist's Perspective.

The COVID-19 pandemic has led to a dramatic rise in the incidence of rhino-orbito-cerebral mucormycosis (ROCM) in India. The purpose of our report is to describe the prevalence of ROCM in the context of SARS-CoV-2 infection during the second Indian COVID-19 wave, as well as its diagnostics proceeding, and to discuss the challenges met in the time frame from the suspected diagnosis to the therapeutic decision in such patients. We conducted a retrospective multicentre case series study at six centres of Sudhalkar and Raghudeep group of hospitals in India. ROCM was confirmed in 38 (2.5%) of the 1546 patients admitted with SARS-CoV-2 infection. The average time to establish a diagnosis was 16 days. In total, 19 (50%) patients suffered from type 2 diabetes and were mostly treated with hypoglycaemic agents (in 90% of cases). The standard of care for SARS-CoV-2 management included systemic steroids therapy, intravenous remdesivir for 5 days, and concomitant prophylactic antibiotic therapy following admission. The median (IQR) blood glucose levels in all patients during the course of hospitalisation was 320 (250.5-375) mg/dl. A total of 16% of patients had an irreparable functional loss, and the mortality was 5%. We may hypothesise that excessive administration of antibiotics that profoundly affects human microbiota, coupled with poorly controlled glycaemia and unprotocolised haphazard steroid administration, contribute to a favourable setting for mucormycosis infections.

Comparison of intraocular lens calculation methods after myopic laser-assisted in situ keratomileusis and radial keratotomy without prior refractive data.

AIM: To compare intraocular lens (IOL) calculation methods not requiring refraction data prior to myopic laser-assisted in situ keratomileusis (LASIK) and radial keratotomy (RK). METHODS: In post-LASIK eyes, the methods not requiring prior refraction data were Hagis-L; Shammas; Barrett True-K no-history; Wang-Koch-Maloney; 'average', 'minimum' and 'maximum' IOL power on the American Society of Cataract and Refractive Surgeons (ASCRS) IOL calculator. Double-K method and Barrett True-K no-history, 'average', 'minimum' and 'maximum' IOL power on ASCRS IOL calculator were evaluated in post-RK eyes. The predicted IOL power was calculated with each method using the manifest postoperative refraction. Arithmetic and absolute IOL prediction errors (PE) (implanted-predicted IOL powers), variances in arithmetic IOL PE and percentage of eyes within ±0.50 and ±1.00 D of refractive PE were calculated. RESULTS: Arithmetic or absolute IOL PE were not significantly different between the methods in post-LASIK and post-RK eyes. In post-LASIK eyes, 'average' showed the highest and 'minimum' showed the least variance, whereas 'average' and 'minimum' had highest percentage of eyes within ±0.5 D and 'minimum' had the highest percentage of eyes within ±1.0 D. In the post-RK eyes, 'minimum' had highest variance, and 'average' had the least variance and highest percentage of eyes within ±0.5 D and ±1.0 D. CONCLUSION: In post-LASIK and post-RK eyes, there are no significant differences in IOL PE between the methods not requiring prior refraction data. 'Minimum' showed least variance in PEs and more chances of eyes to be within ±1.0 D postoperatively in post-LASIK eyes. 'Average' had least variance and more chance of eyes within ±1.0 D in post-RK eyes.

Real-time dynamic changes in intraocular pressure after occlusion break: comparing 2 phacoemulsification systems.

PURPOSE: To compare real-time intraocular pressure (IOP) response to occlusion break event in 2 phacoemulsification systems. SETTING: Iladevi Cataract and IOL Research Center, India. DESIGN: Randomized, experimental study. METHODS: Rabbits were randomized to:Group I (n = 10 eyes), Centurion Vision system with active fluidics, or, Group II (n = 10 eyes), Centurion with Active Sentry. Within each group, parameter set 1 (IOP 30 mm Hg, aspiration flow rate [AFR] 20 mL/min, and vacuum 600 mm Hg) and parameter set 2 (IOP 50 mm Hg, AFR 25 mL/min, and vacuum 600 mm Hg) were tested. Real-time rate of drop and rise of IOP after occlusion break event (mm Hg per second) and percentage reduction of IOP from maximum during nuclear fragment removal were compared. RESULTS: 10 rabbits (20 eyes) were included. Rate of drop of IOP after occlusion break was not significantly different between groups. Rate of rise of IOP was statistically significantly higher in Group II with both parameter sets (199.09 ± 69.28 vs 94.33 ± 45.66 in parameter set 1, P = .006; and 256 ± 45.05 vs 165.25 ± 51.80 in parameter set 2, P = .005), suggesting faster recovery to baseline IOP after occlusion break. The mean percentage reduction of IOP from maximum was significantly higher in Group I (P = .003). CONCLUSIONS: Rise of IOP to baseline after occlusion break event was faster and mean percentage reduction of IOP from maximum during nuclear fragment removal was lower when using the Centurion Vision system with the Active Sentry upgrade compared with the traditional handpiece. The ability to sense IOP at the level of the handpiece with the Active Sentry upgrade allows faster mitigation of surge response.

Current intravitreal therapy and ocular hypertension: A review.

To determine the effect of commonly used intravitreal agents on immediate and long-term IOP elevations and their association, if any, with glaucoma. Literature searches in PubMed and the Cochrane databased in January 2020 yielded 407 individual articles. Of these, 87 were selected for review based on our inclusion criteria. Based on the evidence provided, 20 were assigned level I, 27 level II, and 22 level III. Eight articles were rejected because of poor quality, insufficient clarity, or irrelevance based on standardized protocols set out by the American Academy of Ophthalmology. The studies that reported on short-term IOP elevation (i.e., between 0 and 60 min) showed that an immediate increase in IOP is seen in all patients who receive anti-VEGF agents or triamcinolone acetonide when measured between 0 and 30 min of intravitreal injection and that the IOP elevation decreases over time. The data on long-term IOP elevation were mixed; Pretreatment with glaucoma medications, anterior chamber tap, vitreous reflux, longer intervals between injections, and longer axial lengths were associated with lower IOP elevations after injection of anti-VEGF agents, while the position of the implant vis-à-vis, the anterior chamber was important for steroid therapy. Data were mixed on the relationship between IOP increase and the type of intravitreal injection, number of intravitreal injections, preexisting glaucoma, and globe decompression before injection. There were no data on the onset or progression of glaucoma in the studies reviewed in this assessment. However, some studies demonstrated RNFL thinning in patients receiving chronic anti-VEGF therapy. Most, if not all, intravitreal agents cause ocular hypertension, both in the short term and long term. The functional consequences of these observations are not very clear.

Cortical aspiration - The "POPS" technique.

In the present study, we describe a step-by-step technique for cortex aspiration during cataract surgery- POPS (positioning, occlusion, posterior displacement, and swiping). Firstly, the aspiration probe is positioned under the bulk of cortical fibers beyond the capsulorhexis margin. Subsequently, the aspiration port is occluded with minimal vacuum, and the occluded port is displaced posteriorly to detach the cortical fibers off the anterior capsule. Now, tangential, arc-like swiping movements are performed while gradually increasing vacuum at the same time. The fibers are brought to the center and finally aspirated. This allows complete removal of the equatorial fibers and lens epithelial cells (LEC) with the least stress to the capsulozonular complex. Unlike the conventional technique, which involves the radial pull of cortical fibers, in this technique, there is swiping and posterior displacement of the cortical fibers before pulling towards the center and aspirating. We believe this technique will ensure safer, more effective cortical and LEC removal, reducing zonular stress.

Decoding fluid droplet generation during phacoemulsification and pars plana procedures in the COVID-19 era-An experimental study.

PURPOSE: The purpose of this study is to evaluate fluid droplet spray generation during phacoemulsification (PE), pars plana vitrectomy (PPV), and fragmatome lensectomy (FL) and assess factors affecting these. METHODS: This is an experimental study. PE through 2.2 and 2.8 mm incisions was performed in six goat eyes and four simulator eyes using both continuous and interrupted ultrasound (U/S). PPV and FL were performed in three goat eyes. Generation of visible fluid droplet spray was analyzed from video recordings through the microscope camera and an external digital camera. Hydroxypropylmethylcellulose (HPMC) was applied over the incision site during PE and FL. RESULTS: When PE was performed through both incision sizes, there was no visible fluid droplet spray if the phaco tip was centered in the incision, without sleeve compression. When there was phaco tip movement with the phaco sleeve sandwiched between the tip and the incision wall, there was visible fluid droplet spray generation. It was more difficult to induce fluid droplet spray with 2.8 mm incision, and spray was lesser with interrupted U/S. During PPV, there was no droplet spray. During FL, fluid droplet spray was only seen when U/S was delivered with the fragmatome tip close to the sclerotomy. HPMC impeded droplet spray. CONCLUSION: Fluid droplet generation during PE can be minimized to a large extent by keeping the phaco tip centered within the incision, avoiding sleeve compression. Smaller incision and continuous U/S were more prone to droplet generation. FL should be performed away from sclerotomy. HPMC over incision is recommended.

Visual outcomes after toric intraocular lens implantation in pediatric eyes undergoing cataract surgery.

PURPOSE: To evaluate long-term visual outcomes and complications after toric intraocular lens (IOL) implantation in children with preexisting corneal astigmatism undergoing cataract surgery. SETTING: Iladevi Cataract & IOL Research Center, Ahmedabad, India. DESIGN: Prospective, interventional case series. METHODS: Children with regular corneal astigmatism of at least 1.5 diopters (D) were included. A standardized surgical technique with in-the-bag implantation of a toric IOL was performed. All children were followed up on postoperative day 1 and periodically thereafter, until 36 months postoperatively. The uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and residual refractive astigmatism were documented 36 months postoperatively. Rotational stability of toric IOL was also evaluated through the follow-up duration. Complications, particularly visual axis obscuration (VAO) and glaucoma, were documented. RESULTS: In total, 76 eyes (51 children) were included in the study. Mean age at surgery was 7.41 ± 2.82 years (SD) and mean preoperative keratometric astigmatism was 1.56 ± 2.13 D. The CDVA (logarithm of the minimum angle of resolution [logMAR]) improved significantly from 0.59 ± 0.43 preoperatively to 0.23 ± 0.27 36 months postoperatively (P = .03). Mean postoperative UDVA was 0.32 ± 0.26 logMAR. Mean refractive astigmatism at final follow-up was -0.55 ± 0.40 D, with 74% patients having a UDVA of at least 20/40; 5% of eyes needed VAO treatment and none developed glaucoma. No eye required repositioning of toric IOL until final follow-up. CONCLUSIONS: Toric IOL implantation reduced postoperative refractive astigmatism and gave excellent UDVA at 36 months follow-up in pediatric eyes undergoing nontraumatic cataract surgery.

Bevacizumab as an Adjunct to Trabeculectomy in Primary Open-Angle Glaucoma: A Randomized Trial.

PURPOSE: To compare the outcomes of trabeculectomy using two different routes of bevacizumab administration as an adjunct in patients with primary open angle glaucoma. METHODS: Prospective, randomized, masked trial that included 180 eyes of 180 patients of documented primary open angle glaucoma were eligible for surgery. Patients were randomized to receive either a single intraoperative dose of subconjunctival bevacizumab (1.25 mg, Group I) or topical bevacizumab (5 mg/ml) for 30 days (Group II). One eye was randomly selected, if both were eligible for surgery. All patients underwent a complete ocular and systemic examination. Bleb morphology was examined and scored as per Moorfields system (MBGS) at 1, 3, 6, 12, 18, and 24 months postoperatively. Visual field, fundus photography, and disc analysis were performed. Outcome measures (at one year) included (1) comparison of bleb morphology in both groups, (2) proportion of patients achieving surgical success, and (3) side effects of treatment. RESULTS: The groups did not differ with respect to age, sex, and crystalline lens status. Group II patients had significantly lower vascularity scores for central (P=0.042) and peripheral bleb areas (P=0.042) and peripheral bleb areas (P=0.042) and peripheral bleb areas (n = 88) patients achieved average vascular scores of less than 2.5 (P=0.042) and peripheral bleb areas (n = 88) patients achieved average vascular scores of less than 2.5 (vs. 94%; P=0.042) and peripheral bleb areas (. CONCLUSION: Topical bevacizumab gives a better vascularity profile at one year, but the studied routes appear equally safe and do not seem to affect the outcome in any other way.

Sustained Intraocular Pressure Rise after the Treat and Extend Regimen at 3 Years: Aflibercept versus Ranibizumab.

PURPOSE: To determine the risk factors associated with sustained intraocular pressure (IOP) rise in patients enrolled in the treat and extend (T&E) protocol receiving aflibercept/ranibizumab therapy for 3 years. DESIGN: Retrospective, observational chart review. Setting. Multicentric. Patients. 789 patients (1021 eyes; 602 males) enrolled in T&E using aflibercept/ranibizumab for diabetic macular edema (DME), wet age-related macular degeneration (AMD), or macular edema in retinal vein occlusion (RVO). Intervention. The history, examination (clinical and special investigations), and treatment records were thoroughly scrutinized. Sustained IOP rise was defined as a rise in IOP above baseline by ≥6 mmHg and/or >24 mmHg on 2 or more consecutive visits. The Wilk-Shapiro test was used for confirming normality of data. The Mantel-Haenszel test and generalized estimating equations were used to analyse multicentric data as well as to analyse data from both eyes of the same patients in the event that both eyes were under therapy. The relative risk, chi-square test (with and without Yates' correction), and univariate and multivariate analysis were used wherever appropriate. Statistical significance was set at P < 0.05. The primary outcome measure was the determination of risk factors for sustained IOP rise with ranibizumab/aflibercept therapy. Secondary outcome measures included determining the incidence of IOP rise (short term and sustained), visual field, and retinal nerve fibre layer (RNFL) changes. RESULTS: The mean follow-up was 42.4 months. Male gender, South Asian ethnicity, older age, presence of AMD and vein occlusion, use of ranibizumab, higher number of injections, narrow angles, switch to bevacizumab/ranibizumab, and preexisting glaucoma were associated with sustained IOP rise. No significant visual field and RNFL changes were seen. The overall incidence was 8.91%. No patient required filtering surgery. No patient with IOP rise returned to baseline. CONCLUSION: IOP rise is an important consideration as the chronicity of the condition can eventually lead to glaucomatous changes in eyes with already compromised vision. Follow-ups and use of appropriate therapy can be determined correspondingly.

Intravitreal dexamethasone implant as an alternative to systemic steroids as prophylaxis for uveitic cataract surgery: a randomized trial.

PURPOSE: To determine the utility of the dexamethasone implant (IVD) as an alternative to systemic steroids as prophylaxis against cystoid macular edema (CMO) in patients with chronic, recurrent CMO associated intermediate or posterior uveitis (IU/PU), and cataract undergoing cataract surgery. METHODS: This was a randomized, parallel design, and clinical trial. Patients with IU/PU and cataract scheduled for cataract surgery were randomly assigned to receive the IVD concurrently with cataract surgery (Group 1: 20 patients) or systemic steroids (Group 2: 23 patients) tapered over 4-6 weeks along with uneventful cataract surgery and routine postoperative care. Patients with glaucoma/contraindications to steroids were excluded. All patients were followed up for 6 months. OUTCOME MEASURE: Primary-incidence of postoperative CMO. Secondary-the change in BCVA (corrected distance visual acuity) and Central Subfield thickness (CST) and complications. Appropriate statistical analysis was done. RESULTS: The median age was 47.3 ± 4.23 years (group 1) and 49.12 ± 5.32 years (Group 2). One patient (Group 1) and two (Group 2) developed CMO. The BCVA improved significantly in both groups (p = 0.013). The CST change was insignificant. Four patients (Group 1) required intraocular pressure (IOP) lowering medications. Three patients (Group 2) required early steroid taper. CONCLUSIONS: IVD is a good alternative as prophylaxis in IU/PU and cataract in preventing postoperative CMO.

Impact of fluidic parameters during phacoemulsification on the anterior vitreous face behavior: Experimental study.

Purpose: To evaluate the eff ect of different aspiration flow rates (AFR) and bottle heights (BH) on vitreous face (AVF) during phacoemulsifi cation. Methods: Experimental study in 20 porcine eyes. Transzonular viscodissection was performed between the posterior capsule(PC) and AVF to dissect out the Berger's space. Triamcinolone acetonide was injected into this space to aid visualization with ultrasound B-Scan(USG). Realtime USG was performed during phacoemulsifi cation. Eyes were divided randomly into-Group I: Low parameters(AFR = 20 cc/min, BH = 90 cm, vacuum = 400 mmHg),and Group II: High parameters (AFR = 40 cc/min, BH = 110 cm, vacuum=650 mm Hg). Results: 15 eyes were analysed (8 in Group I; 7 in Group II). In all eyes, forward and backward movement of the PC was seen when going from foot position 0 to 1, or on occlusion break. Amplitude of these movements was much greater in Group II compared to Group I. There was no PC rupture in either group. In 2 of the 7 eyes in Group II, USG showed a sudden, spontaneous dispersion appearance of sono-opaque echoes in the vitreous cavity alongwith disappearance of the well-defi ned, crescentic stained space despite an intact PC. This suggests rupture of the AVF, leading to dispersion of the triamcinolone into the entire vitreous cavity. No AVF rupture was seen in Group I. Conclusion: We report a rarely described entity of AVF rupture with intact PC. The use of high AFR and BH may have clinically invisible detrimental consequences to the anterior vitreous face.

Pro Re Nata Dexamethasone Implant for Treatment-Naive Phakic Eyes with Diabetic Macular Edema: A Prospective Study.

PURPOSE: To determine the utility and safety of the intravitreal dexamethasone implant as primary therapy (pro re nata [PRN]) in phakic eyes with early treatment-naive diabetic macular edema (DME). DESIGN: Prospective, case series. PARTICIPANTS: Patients with diabetes mellitus whose eyes were phakic and had early treatment-naive clinically significant macular edema. METHODS: Patients whose eyes were phakic with DME (<3 months) were included if the central subfield thickness (CST) was >300 µm and corrected distance visual acuity (CDVA) between 0.3 and 1.0 logarithm of minimum angle of resolution. A comprehensive ocular and systemic examination was performed and the implant injected PRN using a standardized technique. Patients had follow-up at least monthly for 2 years. Descriptive statistics were used to analyze categorical variables in terms of size and proportions. The repeated-measures analysis of variance test was used to determine the change in CDVA, CST, intraocular pressure, and hard exudate area over time. MAIN OUTCOME MEASURES: The primary outcome measure was the determination of the change in CDVA at month 24 from baseline. Secondary outcome measures included determining the change in CST, median number of injections, proportion gaining 15 letters, and complications, if any. RESULTS: A total of 153 patients (85 males) were included. At 2 years, mean CDVA improved from 0.62 to 0.4 logarithm of minimum angle of resolution, and median CST improved from 397 to 236 µm. The median number of injections was 1.6. Cataract developed in 3 patients with a clear lens, and 31 patients required topical antiglaucoma therapy. Proliferative disease developed in 4 patients, which was managed with panretinal photocoagulation. None of the study patients required rescue therapy. CONCLUSIONS: In patients with treatment-naive phakic eyes who had DME, primary therapy with the intravitreal dexamethasone implant PRN (for 2 years) resulted in significantly improved mean CDVA. A fifth of the patients required control of intraocular pressure, and new-onset cataract developed in 3 of 153 patients.

Comparative evaluation of femtosecond laser-assisted cataract surgery and conventional phacoemulsification in eyes with a shallow anterior chamber.

PURPOSE: To compare intraoperative performance and postoperative outcomes between femtosecond laser-assisted cataract surgery (FLACS) and conventional phacoemulsification in eyes with a shallow anterior chamber (AC). SETTING: Iladevi Cataract & IOL Research Centre, India. DESIGN: Prospective randomized masked clinical study. METHODS: Patients undergoing cataract surgery with a shallow AC (<2.5 mm) were randomized to have FLACS (Group 1, n = 91) or conventional phacoemulsification (Group 2, n = 91). Patients were followed up at 1 day, 1 week, and at 1, 3, and 6 months. The primary outcome measure was central corneal thickness (CCT). The secondary outcome measures were corneal clarity, AC cells and flare, endothelial cell density (ECD), coefficient of variance, hexagonality, and uncorrected distance visual acuity (UDVA) at 1 week. RESULTS: The study comprised 182 eyes (91 in each group) The cumulative dissipative energy was lower in the FLACS group (P < .05). The mean CCT was significantly lower with FLACS (540.40 µm + 49.40 [SD] vs 556 + 12.5 µm, P = .03) at 1 day and 1 week (535.5 + 44.3 µm vs 551 + 40.8 µm, P = .04), with fewer eyes having higher than grade 2 AC cells and flare with FLACS (85% vs 72%, P = .056) at 1 day and 1 week (15% vs 28%, P = .03). At 1 week, the UDVA was better with FLACS (0.089 ± 0.31 logarithm of the minimum angle of resolution [logMAR] vs 0.178 ± 0.65 logMAR, P = .042). At 6 months, the reduction in ECD was lower in the FLACS group; however, the difference was not statistically significant. CONCLUSION: In eyes with shallow ACs, compared with conventional phacoemulsification, FLACS maintained clearer corneas, showed less increase in CCT, lower AC inflammation, and better UDVA in the early postoperative period.

Incorporating Optical Coherence Tomography in the Cataract Preoperative Armamentarium: Additional Need or Additional Burden?

PURPOSE: To determine the usefulness of preoperative optical coherence tomography (OCT) examination to detect asymptomatic macular abnormalities in patients scheduled for cataract surgery. METHODS: Design: Prospective, interventional case series. SETTING: Iladevi Cataract and Visakha Eye Center, Ahmedabad, India. STUDY POPULATION: Patients undergoing cataract surgery and intraocular lens (IOL) implantation for senile cataracts. Preoperatively no retinal/macular pathology was identified on clinical evaluation. INTERVENTION: All eyes underwent macular 5-line raster evaluation using spectral-domain OCT before and after cataract surgery (monthly for 3 months). Central subfield thickness (CST) analysis was done. OUTCOME MEASURES: The primary outcome measure was determining the incidence of asymptomatic retinal lesions on OCT examination in clinically "normal" maculas. Secondary outcome measures included documenting change in corrected distance visual acuity and OCT thickness postoperatively. RESULTS: A total of 1444 eyes were evaluated. OCT revealed asymptomatic lesions in 133 (9.21%) patients. At 3 months, all eyes showed significant median visual improvement (from 0.45 ± 0.13 logMAR to 0.06 ± 0.08 logMAR; P = .015) and insignificant median CST change (from 223.34 ± 21.1 µm to 249.12 ± 19.24 µm; P = .19). One eye showed increased vitreomacular traction (3 months). Patients with asymptomatic lesions did not have significantly worse postoperative visual outcomes at 3 months (from 0.52 ± 0.16 logMAR to 0.14 ± 0.1 logMAR; P = .12). CONCLUSION: A total of 9.21% patients with clinically normal maculas had subtle pathology detected on OCT, but this subset of patients did not have worse postoperative visual outcomes compared to eyes with normal OCT scans. Thus, a careful pre-cataract surgery fundus examination remains an essential part of the presurgical patient evaluation.

Safety and Efficacy of a New Phakic Posterior Chamber IOL for Correction of Myopia: 3 Years of Follow-up.

PURPOSE: To evaluate the outcomes of a new posterior chamber phakic intraocular lens (IPCL; Care Group, Baroda, India) to correct myopia. METHODS: This prospective, observational case series included 30 eyes undergoing implantation of the IPCL for high myopia (> -8.00 diopters [D]). Uncorrected (UDVA) and corrected (CDVA) distance visual acuities, refraction, vault, endothelial cell loss, and adverse events were evaluated 3 years after implantation of the IPCL for high myopia. RESULTS: The mean spherical equivalent decreased from -16.50 ± 5.62 D preoperatively to -0.89 ± 1.27 D at 3 years. The mean UDVA and CDVA were 0.38 ± 0.21 and 0.24 ± 0.09 logMAR. No eye lost any lines and 49% of eyes gained one line or more of CDVA. One eye (3.3%) developed anterior subcapsular cataract, but did not require cataract surgery at 3 years of follow-up. Two eyes (6.6%) developed a mild transient increase in intraocular pressure, which required topical medication only for 3 months. The percentage of endothelial cell loss at 3 years was 9.73% ± 6.72%. The IPCL vault tended to reduce with time, from a mean of 626.66 ± 188.98 µm at 1 month to 540.22 ± 210.76 µm at 3 years. No vision-threatening complications occurred. CONCLUSIONS: Implantation of the new posterior chamber phakic IOL is an effective alternative to correct high myopia, showing good outcomes at 3 years. [J Refract Surg. 2018;34(12):817-823.].

Five-Year Postoperative Outcomes of Bilateral Aphakia and Pseudophakia in Children up to 2 Years of Age: A Randomized Clinical Trial.

PURPOSE: Comparative evaluation of complications and visual outcomes following bilateral congenital cataract surgery in children up to 2 years of age with and without primary intraocular lens (IOL) implantation at 5 years follow-up. DESIGN: Randomized controlled clinical trial. METHODS: Sixty children (120 eyes) up to 2 years of age undergoing bilateral congenital cataract surgery were randomized to Group 1, primary aphakia (n = 30), or Group 2, primary IOL implantation (pseudophakia) (n = 30). A single surgeon performed surgeries with identical surgical technique. All patients were followed up regularly until 5 years postoperatively. At each follow-up, glaucoma, visual axis obscuration (VAO) requiring surgery, and inflammation (cell deposits, posterior synechiae) were assessed. Visual acuity was assessed until 5 years follow-up. The first operated eye was selected for statistical analysis. RESULTS: Median age of the patients at time of surgery was 5.11 months (aphakia group) and 6.01 months (pseudophakia group) (P = .56). Five years postoperatively, incidence of glaucoma was 16% and 13.8% in Groups 1 and 2 (P = .82). Incidence of posterior synechiae was significantly higher in the pseudophakia group (27.6%) compared to the aphakia group (8%) (P = .004). VAO requiring surgery was seen in 8% and 10.3% of eyes in Groups 1 and 2 (P = .76). Mean logMAR visual acuity at 5 years follow-up was 0.59 ± 0.33 and 0.5 ± 0.23 in Groups 1 and 2, respectively (P = .79). However, more eyes in the pseudophakic group started giving documentable vision earlier in their postoperative follow-ups. CONCLUSIONS: Incidence of postoperative complications was comparable between the groups, except for a higher incidence of posterior synechiae in pseudophakic eyes. Visual rehabilitation was faster in the pseudophakic group.

Comparison of ocular wavefront aberrations in subluxated lenses before and after lens extraction with intraocular lens implantation.

PURPOSE: To compare the change in ocular higher-order wavefront aberrations (HOAs), visual acuity, and modulation transfer function (MTF) after lens extraction with intraocular lens (IOL) implantation in patients with subluxated lenses. SETTING: Iladevi Cataract & IOL Research Centre, Ahmedabad, India. DESIGN: Prospective case series. METHODS: Eyes with subluxated lenses having lens extraction with IOL implantation were included. Capsular bag fixation with in-the-bag IOL implantation or sutured or sutureless scleral fixation of the IOL was performed. Aberrometry was performed preoperatively and 6 months postoperatively. The following were compared: root-mean-square (RMS) value for total ocular HOAs, coma aberration, spherical aberration, MTF, and corrected distance visual acuity (CDVA). RESULTS: Of the 39 eyes with subluxated lenses, 26 eyes had Cionni ring fixation, 9 had sutured scleral fixation, and 4 had intrascleral fixation of the IOL. The mean preoperative and postoperative values, respectively, were as follows: RMS HOAs, 10.5 µm ± 9.5 (SD) and 4.73 ± 4.6 µm (P < .001); coma aberration, 2.46 ± 2.4 µm and 0.11 ± 0.1 µm (P = .03); and spherical aberration, 0.37 ± 0.9 µm and 0.02 ± 0.06 µm (P = .02). The MTF improved significantly in all eyes (mean 0.05 ± 0.02 preoperatively and 0.32 ± 0.16 postoperatively) (P = .005). The CDVA was statistically significant improved 6 months postoperatively. CONCLUSION: Lens extraction with IOL fixation in eyes with subluxated lenses significantly reduced ocular HOAs and improved the MTF.

Paradigms for Pediatric Cataract Surgery.

Pediatric cataract surgery has seen several advances in techniques, technologies, and conceptual practices. Pediatric cataract management heavily depends on a combined effort, not only from the ophthalmologist, but also the parents, the anesthetists, and the supporting staff members (eg, optometrists, orthoptists, patient coordinators). Surgical management, though critical, is not the only consideration for these children. Continuing visual rehabilitation and monitoring for complications remain key elements even after the surgery is done. Pediatric cataract surgery is a complex issue best left to surgeons who are familiar with the surgical paradigms and its long-term complications. Key components of surgery are management of posterior capsule and anterior vitreous and intraocular lens (IOL) implantation. It is a preferred practice today to perform a primary posterior capsulorhexis with anterior vitrectomy in younger children (up to 3 to 5 years old). Even in older children (up to the age of 8 years), performing a posterior capsulorhexis without anterior vitrectomy is the preferred approach. Above the age of 8 years, the posterior capsule can be left intact. In-the-bag IOL implantation is almost becoming a norm for children above the age of 1 year. Though there is no universal consensus regarding the earliest age for primary IOL implantation, many surgeons increasingly prefer primary IOL implantation even in infants. Alternate approaches that can avoid anterior vitrectomy like optic capture through the posterior capsulorhexis and bag-in-the-lens are also gaining more and more popularity.

Postoperative outcomes of intraocular lens implantation in the bag versus posterior optic capture in pediatric cataract surgery.

PURPOSE: To compare complications in children up to 4 years old having cataract surgery with intraocular lens (IOL) implantation using 2 techniques: in-the-bag IOL with anterior vitrectomy or optic capture of IOL with no anterior vitrectomy. SETTING: Iladevi Cataract & IOL Research Centre, Ahmedabad, India. DESIGN: Prospective randomized control clinical trial. METHODS: The study included children having cataract surgery with IOL implantation. Patients were randomized to Group 1 (in-the-bag 3-piece hydrophobic acrylic IOL [Acrysof MA60AC] with anterior vitrectomy) or Group 2 (optic capture of the same IOL without anterior vitrectomy). Intraoperative complications were documented. Postoperative visual axis obscuration (VAO), glaucoma, cell deposits on the IOL, and posterior synechiae were compared at 1, 3, 6, and 12 months. RESULTS: The study comprised 61 children (61 eyes). The mean ages were 14.8 months ±11.47 (SD) in Group 1 (n = 30) and 18.2 ± 11.47 months in Group 2 (n = 31). Overall, only 1 eye in Group 1 developed a VAO requiring membranectomy 4 months postoperatively, and 2 eyes in Group 1 developed glaucoma over 12 months (P = .49). Intraocular lens cell deposits and posterior synechiae were comparable between groups. The IOL could not be captured in 5 eyes (16.1%); no complications occurred in these eyes. CONCLUSIONS: Optic capture of 3-piece hydrophobic acrylic IOLs could be achieved in most eyes. The VAO, glaucoma, and inflammation were comparable 12 months postoperatively. Thus, optic capture of an IOL is an alternative surgical technique that can be used to avoid vitrectomy, even in children younger than 4 years.